I confess that there are strong reasons for me to feel strongly on the paediatric deaths in Gorakhpur. I am a native of this mofussil town and have been residing here permanently since I relocated to India after more than three decades abroad.
The entire medical community in India should hang its head in shame over what has happened. Close to 70 small children, some even neonates, have died in the big hospital affiliated to the local B R D Medical College in the last three days. And those are the official figures!
We also have to take into account that deaths from encephalitis in the private hospitals never get reported. Additionally more than 50% of the encephalitis cases in the interiors never get to reach the city hospitals.
By now, thanks to extensive media coverage, most of us would have gained acquaintance of the issues involved. The representatives of the media noticed a dramatic hike in mortality rates in the last few days. It was then discovered that the hospital had run out of oxygen supplies because of the non-payment to the suppliers. The hike in the mortality rate, more than twice over the preceding days, coincided with the oxygen supplies being terminated.
The government maintains that none of the deaths could be attributed to the non-availability of oxygen and as per usual practice, has set up a committee to provide it with a report. Chief Minister Adityanath has assured of strict action if someone is found to have been guilty and negligent.
The relatives of the deceased, however, maintain that their wards were denied oxygen and told that it was not available. Two of them revealed that they were asked to work on with an Ambu valve for hours. Ambu, as we all know, is only meant to be utilized as a temporary measure for a few minutes and is certainly not going to be helpful in cases where high concentration oxygen is needed. In one case, a parent came up with a heart-wrenching tale of the attending doctor not providing him with a death certificate after his child had passed away.
Under the circumstances, it would be very difficult to get at the whole truth. But some disturbing facts have emerged. It would appear that the supplier of oxygen supplies had been in correspondence with the principal over the non-payment of his bills since February 2017 and had actually sent him a legal notice to state that if the payment was non forthcoming, he would terminate the supplies. It is worth noting that the person who was supposedly negotiating with the supplier, albeit unofficially, was the principal’s wife. There is disparity between the versions of the principal and the government. Health Minister Siddhartha Nath Singh has stated that the government had released sufficient funds immediately after being notified but the supplier maintains that he received a part of the payment only after the deaths had taken place.
Vice Principal Dr Kafeel Khan, in-charge of the encephalitis ward, was presented in the national media as a hero who brought in oxygen cylinders from a friend’s clinic and attempted to resuscitate the patients on being notified of the calamity. Mystifyingly, he was suspended on 13th August and some very unsettling information about him was leaked to the local media.
All in all, the whole situation was reduced to a cruel farce and the only sufferers were small children and their unfortunate relatives who had reposed so much trust in the hospital.
But there are certain facts that cannot be denied. The first and the foremost is that Gorakhpur has been in the throes of encephalitis for at least 25 years, which has resulted in thousands and thousands of deaths. Most disturbingly, there has been absolutely no effort on the part of successive governments to launch an effective programme to combat this menace. Platitudes have been offered on a platter by every politician worth his salt but that has never been translated into effective action, which a tragedy like this necessarily warrants. No government, central or state, has its hands clean in this regard. In an interview with a television channel, I had described the situation as a disaster which was just about waiting to happen.
I have myself been a member of several medical relief missions in my career and have always been astounded at the apathy I observed over this issue notwithstanding the protestations from the politicians. However, I personally feel that it is a failure at every level that has resulted in this calamity. I am particularly distressed at the inaction from my own profession. I have known the medical profession in other countries to raise a hue and cry when a problem of this magnitude emerges. Surely that was warranted here and it was not forthcoming. There could be a variety of reasons for it but the essential fact remains; we did not demonstrate empathy to our fellow human beings when it was needed so badly. The crisis was widely known to everyone but there was no hue and cry from the medical fraternity to force the powers that be to act appropriately. In that regard, we failed in our obligations and as a member of the fraternity I am as guilty as anyone. My head hangs in shame.
I have no realistic expectations from the politicians but even then I was flabbergasted to note the disgraceful spectacle of scoring brownie points that continues to dominate our television screens even while the crisis is still on the horizon and the relatives are still grieving. Two statements stand out for their extreme insensitivity. Union Minister of State for Health Faggan Singh Kulaste described the deaths as a planned conspiracy against the recently installed government. By any stretch of imagination, such insensitivity was repugnant to say the least. Not to be outdone, the provincial Health Minister Siddhartha Nath Singh, in a press conference, went on to state that 20 deaths in a day in August was not excessive! A bizarre statement to put it very mildly!
It is pointless at this stage to debate about the exact causes of the tragedy. The government has reeled off statistics which most of us, including myself, are in no position to confirm or contradict. And sadly I do not see the prospect of any ministerial resignation. When asked where the buck should stop, Siddhartha Nath Singh could only retort by stating that he was only the health minister while the medical college was under his cabinet colleague Ashutosh Tandon. Technically he is right. But what he very astutely omitted to mention was that all the primary health centres (PHC) in the province were his responsibility. The PHCs serve as the first point of contact for the people in the interiors. They are expected to diagnose the disease early and commence the treatment to ensure that it does not progress to the stage whereby removal to a district hospital or a medical college becomes necessary. Anyone who has taken the trouble to examine the PHCs in UP would know that most of them are locked even during the working hours and even when they are open, the doctor is hardly ever found; they are usually busy with their private practices in a nearby town having arranged with the local CMOs to share a proportion of their government salaries. That is probably the worst kept secret in the province and I would be disinclined to believe that Singh is not aware of this massive scam.
In a democratic polity there is always a healthy tradition of ministerial accountability that is available. One of the foremost examples of that in India is that of a Railway Minister in the 1950’s who tendered his resignation following a train accident for which he could in no way be held responsible. He later on became a popular prime minister. Perhaps Singh could emulate a lesson or two from this great man.
But I believe our major focus now should be to ensure that a tragedy like this never takes place again. That is the very least we owe to everyone. If the calamity forces the powers that be to look in this direction, at least some lesson would have been learned.
Sometime ago, I had published a column on this very portal when Adityanath had indicated that he was going ahead with plans for an AIIMS in Gorakhpur and there was mass euphoria over the prospect. Adityanath had claimed that this would help eliminate the problem of encephalitis in this area.
I would stand corrected but I believe I was the only columnist who had expressed reservations in my column and that had brought me some metaphorical brickbats from the locals. I was therefore heartened to note that Sujatha Rao, one of the most distinguished ex union health secretaries, share my concerns in this regard.
Anyone who has had dealings with infectious disease control would attest that in order to ensure proper containment, exclusive emphasis on secondary and tertiary healthcare is bound to fail. In my very long medical career, I have seen many infectious diseases being brought under control in different parts of the globe. The main focus of any such successful programme is emphasis on preventive and primary healthcare. And it is these that are missing not just in UP but in the whole country. Those who may have perused my earlier column may recall that I had suggested building up of primary healthcare infrastructure and beefing up health education.
The best and the most successful healthcare systems in the world are all based on an edifice of primary healthcare. I shall not mention the Norwegian, Danish, Swedish and Swiss healthcare systems; they are after all prosperous countries. Even the NHS in the UK, in its heyday, was effective because of its emphasis on primary healthcare. But we can certainly take a lesson or two from Cuba, a third world country, which has in a very short span managed to eliminate nearly all the serious infectious diseases with remarkable healthcare statistics without relying on secondary and tertiary healthcare, through just building up a solid preventive healthcare base and effective primary healthcare making it largely community based. I have penned a column on my impressions of the Cuban healthcare system which has earned it plaudits even from those like myself who have been critical of its political system.
If we are really serious about improving our healthcare system, we need to stress on building up the primary healthcare system which is almost non-existent in this country. Sadly there have been no credible efforts in that direction. Even though the Medical Council of India had approved MD courses in Family Medicine, until two years ago only two medical colleges had expressed any enthusiasm. Dr Raman Kumar has been a pioneer in attempting to convince the powers that be to change their mindsets.
It stands to reason that if a trained family practitioner is available as the first point of contact, no one would feel the need to seek consultation from the tertiary healthcare centres that are mushrooming all over the country and which are making healthcare prohibitively exorbitant for most. I sincerely doubt a tragedy like the one in Gorakhpur would have taken place if we had a flourishing healthcare system based on primary healthcare provision. That was the reason I was less than enthusiastic about an AIIMS in mofussil towns and was advocating a family medicine training institute instead.
If this tragedy alerts us to this reality, we can hopefully prevent any further eminently avoidable crisis that we are navigating through today. Is anyone listening?
by Dr Ashoka Jahnavi Prasad
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